TEAM TRIAGE REDUCES DEPARTMENT WALKOUTS, IMPROVES PATIENT CARE

Summary
The emergency department at Vanderbilt University Medical Center established a program in which
patients are quickly assessed in a triage area by a team consisting of a physician, a nurse, and a
paramedic. Patients with urgent problems are promptly moved to a treatment room. Patients with
nonurgent problems are tested and/or treated in the team triage area. They are then released or
return to the waiting area until test results and a treatment room are available. As a result of the
program, most patients see the triage doctor within 10 minutes of arriving, the percentage of
patients who leave without treatment has decreased from 5 percent to under 1 percent, and patient
satisfaction has increased markedly.

Evidence Rating 
Moderate: The evidence consists of pre- and post-implementation comparisons of waiting times,
patient walkouts, and patient satisfaction.

Developing Organizations
Vanderbilt University Medical Center Emergency Department
July

Patient Population
Geographic Location > City

WHAT THEY DID

Problem Addressed
The number of patients visiting hospital emergency departments (EDs) is steadily rising in the
United States, leading to longer waiting times and higher patient dissatisfaction. Many patients
leave without receiving treatment, jeopardizing their health and costing hospitals potential
revenue.
 More ED patients, fewer EDs to care for them: In 2003, ED visits reached nearly 114 million, a
26 percent increase over the previous decade. During this time, the United States
experienced a net loss of 425 EDs.1
 Long waiting times: The typical patient spent 4 hours in the ED in 2006, up from 3.7 hours in
2005. Comparisons with earlier time periods suggest even larger increases in waiting times;
for example, between 1997 and 2004 the median wait time for ED patients presenting with
acute myocardial infarction (AMI) increased by 150 percent. 2
 More leave without being treated: The longer patients wait, the more likely they are to leave
without treatment and the less satisfied they are with the ED. 3 The Vanderbilt ED
experienced all these trends, with rising patient volumes and longer waits contributing to a 5
percent walkout rate.

Description of the Innovative Activity

Team Triage ensures that people with severe illnesses and injuries receive prompt treatment in the
ED, while those with less urgent problems are treated and released. The goal is for patients to see a
doctor within 10 minutes of their arrival. Key program components include:
  Quick registration: Arriving patients sign in by providing basic information—such as their
name, Social Security number, and chief complaint—to the ED registrar.
 Triage process: The triage area has three rooms and is staffed by a team that includes a
physician, a nurse, and a paramedic. The nurse performs standard triage in one room. The
patient then moves to a second room to be seen by the physician, who decides if any tests
are warranted and whether immediate care is needed; care is then provided as follows:
o Immediate care required: If immediate care is needed, the patient is transferred to a
treatment room and treated by another ED physician. Typical cases in which
immediate care is needed include possible acute myocardial infarction, stroke, or
severe respiratory problems.
o Nonurgent cases, no diagnostic tests required: In nonurgent cases that do not
require diagnostic tests (e.g., a sprained ankle, sinus infection, or small laceration),
the patient is treated and released.
o Nonurgent cases, diagnostic tests required: In nonurgent cases that require
diagnostic tests, the physician orders the appropriate test and temporary pain relief.
(For example, a patient with an injured arm that might be broken would have an x-ray
and receive an ice pack, and a patient with a sore throat would get a throat culture.)
The patient returns to the waiting room to await the test results. When the results
come back, the patient either sees a physician in a treatment room or is released if no
further treatment is warranted.
 Followup registration: The ED registrar conducts a followup interview to obtain billing and
insurance information; this interview is conducted in either the waiting room or at the
bedside in the ED treatment room, after the patient has received the initial examination.
 Hours of operation: Team Triage operates from 11 a.m. to 11 p.m.—hours when patients in
the waiting room typically outnumber treatment rooms. During off-peak hours, Team Triage
is not necessary because patient volume does not exceed the ED's capacity.

DID IT WORK?
Results
Team Triage has reduced the time it takes for patients to a see a doctor from several hours to 10
minutes; the percentage of patients who leave without getting treatment declined from 5 percent
to less than 1 percent. Results are as follows:
 Shorter wait to see a doctor: Most patients see a doctor in the triage area within 10 minutes
of arriving, a vast improvement from the old system that often entailed waits of several
hours. Those with true emergencies are able to be treated by a physician in an average of 37
minutes.
 Fewer walkouts: The walkout rate decreased from 5 percent pre-implementation to under 1
percent, which has been maintained since the start of the program.
 Increased revenue: A hospital analysis has indicated that the increased emergency
department and inpatient revenue due to fewer walkouts totals nearly $500,000 annually.
 Constant length of stay: Despite a steady increase in the number of patients in recent years
(from about 40,000 in 2005 to more than 50,000 in 2007), the total time that patients spend
 at the ED has stayed about the same, averaging 358 minutes in 2007 (most recent data
available).
 Improved patient satisfaction: A survey of patients at 199 EDs by Professional Research
Consultants found that after implementing Team Triage, Vanderbilt's ED rose from the
75th to the 95th percentile on likelihood of recommending the ED to others, and from the
80th to 97th percentile on overall quality of care. These results led to the Vanderbilt
ED winning Professional Research Consultants' 2007 Gold Achievement Award in Teamwork
and Overall Quality.

Evidence Rating 
Moderate: The evidence consists of pre- and post-implementation comparisons of waiting times,
patient walkouts, and patient satisfaction.

HOW THEY DID IT

Context of the Innovation
Vanderbilt University Medical Center is anchored by Vanderbilt University Hospital, a 600-bed
institution in Nashville. The hospital's ED is a Level 1 Trauma Center with 45 beds serving a population
of 4.5 million people. The ED treated over 40,000 people in 2005 and over 55,000 in 2008. Several
days each week, roughly one-half of the ED's beds are occupied by patients who are waiting for a
hospital bed to become available. Team Triage was implemented at a time when hospital officials
were looking for effective ways to handle the increasing number of patients, especially nonurgent
patients who needed to see a doctor but did not need emergency treatment. Such patients often
were forced to wait for 5 hours or more before being called to a treatment room, and a significant
percentage were leaving without ever seeing a doctor. Vanderbilt University Medical Center
developed the program after seeing a conference presentation by officials at Inova Fairfax Hospital
in Falls Church, VA, which had established a similar program.

Planning and Development Process

Implementing Team Triage at Vanderbilt University Medical Center required these steps:
 Facility redesign: The ED was redesigned to create a triage area large enough to comfortably
accommodate three patients and a three-person medical team.
 Rotation of physician staff: Administration identified attending physicians who were
interested in working parts of their shifts in triage. Residents were not included in the triage
rotation.
 Initial program implementation: Three physicians were selected to practice with the concept
and identify what worked and what did not work. 

Resources Used and Skills Needed

 Staffing: One additional doctor was hired to ensure that the triage area and the treatment
rooms had adequate coverage. 
 Costs: The cost of hiring the additional physician for Team Triage has been offset by the
increased revenues from the decrease in patient walkouts. The renovation of the Team
Triage area cost approximately $40,000.
Funding Sources
Vanderbilt University Medical Center

Tools and Other Resources

More information is available at www.VanderbiltEmergency.com.

ADOPTION CONSIDERATIONS
Getting Started with This Innovation
 Challenge conventional wisdom about triage: Triage has been performed the same way for
50 years. Patients see triage as a barrier to seeing the physician; therefore, hospitals should
consider how triage can enhance patient service. If ED beds are available, then patients can
receive treatment in the ED, but when beds are not available they can be treated in the triage
area.
 Assign attending physicians to the triage role: Team Triage should be staffed by experienced
physicians with an interest in this type of care, rather than by a multitude of physicians who
are  rotating through the role. In addition, Team Triage works best when the triage area is
staffed by attending physicians rather than medical residents, who tend to order
unnecessary tests that may keep patients from quickly moving to the next step (release or a
treatment room).
 Promote teamwork: Team Triage requires all staff to work together. Promote teamwork by
encouraging staff to speak highly of each other when talking to the patients. When nurses
overhear a physician talking positively about them, they feel very validated, and the patient
feels that they are in very good hands. Departmental successes should be celebrated with
the inclusion of all team members.
 Expect some resistance: Team Triage requires a change in traditional employee roles, which
may lead to job dissatisfaction; tips for enhancing staff support include the following:
o Physicians: Doctors who are used to seeing patients one at a time in a treatment room
may dislike the more hectic atmosphere of the triage area. However, if a sufficient
number of doctors favor the new system, physicians may be able to choose whether they
want to work in the triage area or the treatment room.
o Nurses: Nurses who are used to making initial triage decisions may be unhappy about
relinquishing this responsibility to physicians. There is no magic bullet for dealing with
this dissatisfaction, but one can emphasize that Team Triage serves a vital purpose
(enabling patients to see a doctor more quickly), that Team Triage reduces nurses' legal
liability, and that nurses retain triage decision-making authority during off-peak hours.

Sustaining This Innovation

 Share success: Make sure all staff are aware of improvements that result from Team Triage,
such as decreases in patient waiting times and walkouts.

Use By Other Organizations

A number of hospitals have sent representatives to Vanderbilt University Medical Center to examine
how Team Triage works, including Massachusetts General Hospital, Barnes-Jewish Hospital at
Washington University Medical Center, and University of North Carolina Health Care.
REACTION:
This has been very effective in the emergency departments today, and hospitals should really
utilize this idea. Not only does it benefit the clients because they get the care / treatment that they
needed, but also the hospital gets higher revenue because of decreased walkout of patients from
the emergency room.

Separate Emergency Center for Older Patients Leads to High Levels of Patient
Satisfaction, Detection of Polypharmacy, Increased Volume of Patients, and
Low Rate of Return Visits

Summary
Holy Cross Hospital established a separate senior emergency center to treat patients 65 and older
who are experiencing acute, but not life-threatening health problems. The center has several
physical features intended to make seniors' stays more comfortable and safe, such as separate
rooms, thicker mattresses, special lighting, reduced-glare floors, and a blanket warmer. In addition,
all staff have received specialized training in geriatrics, enabling them to provide enhanced care
tailored to seniors' needs. A geriatric social worker follows up with high-risk patients within 24 hours
of discharge, while an administrative assistant conducts additional followup with all patients a few
days after release. Patients treated at the senior emergency center report high levels of satisfaction
with their treatment. The center has increased the number of patients identified as taking
inappropriate medication or medication doses, and has also experienced an increased volume of
patients and low rates of return visits to the emergency department.

Evidence Rating
Suggestive: The evidence consists of post-implementation results from patient satisfaction surveys,
along with data on the percentage of patients who were taking an inappropriate medication or
medication dose, treated in the senior emergency center, and returned to the emergency
department after an initial visit.

Developing Organizations
Holy Cross Hospital

Silver Spring, MD
Date First Implemented
2008
November

Patient Population
Age > Senior adult (65-79 years); Aged adult (80+ years); Vulnerable Populations > Frail elderly

WHAT THEY DID

Problem Addressed
The over-65 population in the U.S. is growing rapidly, and many seniors have chronic illnesses that
result in frequent emergency department (ED) visits. Providing seniors with optimal emergency care
can be challenging due to the fast-paced, hectic environment in most EDs, staff time constraints, and
limited resources to provide patients with the needed followup support. 

 A growing population, with many chronic illnesses: The population of seniors in the U.S. is
growing rapidly, with growth expected to continue in coming decades, especially among
those over 80. In Montgomery County, MD, for example, 70 percent of the anticipated
population growth over the next 2 decades will be among people older than 65,1 and the
number of residents age 65 and older not living in nursing homes is expected to double over
a 30-year period, from roughly 92,000 in 2000 to 187,000 in 2030. 2 Many seniors have chronic
illnesses (e.g., diabetes, heart failure, osteoporosis, chronic obstructive pulmonary disease,
dementia) that result in frequent ED visits.

 Stressful ED experience: Seniors often find the ED to be overwhelming due to factors such as
loud noise, a lack of privacy, and the fast pace of interactions with staff. Poor hearing and
neurological limitations often make it hard for seniors to understand what is occurring in the
ED.

 Little followup, leading to return visits: ED care traditionally focuses on treating patients'

immediate health concerns and discharging them as quickly as possible so that additional
patients can be seen. Given the emphasis on speed, older patients often do not receive
or understand instructions on what they should do to address their health issues once they
return home. In addition, factors such as limited transportation, unfamiliarity with
technology, and difficulty dealing with bureaucracy may prevent them from going to
followup doctor's appointments and/or obtaining needed medications in a timely manner. As
a result, seniors have a high rate of return visits to the ED, leading to high costs.3

Description of the Innovative Activity

Holy Cross Hospital established a separate senior emergency center to treat patients 65 and older
who are experiencing acute, but not life-threatening health problems. The center has several
physical features intended to make seniors' stays more comfortable and safe, such as separate
rooms, thicker mattresses, special lighting, reduced-glare floors, and a blanket warmer. In addition,
all staff have received specialized training in geriatrics, enabling them to provide enhanced care
tailored to seniors' needs. A geriatric social worker follows up with high-risk patients within 24 hours
of discharge, while an administrative assistant conducts additional followup with all patients a few
days after release. Key elements of the senior emergency center include the following:

 Location and set-up: The center adjoins the main ED, in space formerly used as a
patient overflow area. It contains a nursing station, eight patient rooms, and one large room
for private family consultations.

 Environmental enhancements: The center includes a number of physical features designed to

reduce patients' anxiety and discomfort and enhance safety:

o Larger, private rooms: Unlike a typical ED with cubicles separated by curtains, the

senior center has rooms divided by thick walls that are large enough for
a comfortable chair for a family member or visitor. Patients can converse with staff
and guests with reduced noise distraction from other staff-patient interactions. To
further minimize noise, staff communicate via wireless phones to limit the use of the
intercom system.

o Comfortable beds and appealing environment: Beds have mattresses twice as thick

as those in the standard ED that are specially designed to prevent skin
breakdown and pressure ulcers. Walls have been painted a warm gold with
contrasting white space, which appeals to the aging eye and reduces stress. Patients
can control the overhead lighting with a dimmer switch. Each room has a television,
allowing patients to watch programs or nature images or listen to soothing music.
Each room also has a large clock and a phone with larger than normal buttons.
Patients can request coffee, tea, bouillon, or juice, and can use blankets directly from
a blanket warmer.

o Additional safety features: Other safety features include a floor made of

nonreflecting faux wood rather than the typical linoleum (which produces glare that
can cause missteps and falls) and hand rails that line the center's walls to further
reduce the risk of falls. Staff rely on digital handheld cardiac monitoring devices to
 monitor patients instead of large machines that can make it hard for patients to
move around.

 Staff trained in geriatric care: All emergency physicians and nurses receive specialized

training on common health problems facing seniors and on strategies for providing
compassionate care to them. Two staff members with additional expertise in geriatric care—
a nurse practitioner and social worker—work exclusively with patients in the senior center.
The social worker serves as a general problem solver who gets to know patients as much
possible, makes sure they are comfortable and not left alone for long periods, tries to find
underlying causes to the problem(s) that led to the ED visit, and answers questions about
care (e.g., what will happen next and when this will occur).

 Screening for polypharmacy: When a senior patient is noted to be on 5 or more medications

(including prescription and over-the-counter drugs, as well as herbal remedies), nurses are
trained to initiate a "Senior Polypharmacy" referral. This information is automatically
transmitted to the pharmacist, who reviews the medication profile and identifies drugs or
doses of medications that are not appropriate for older adult patients. If an inappropriate
drug or dose is detected, the pharmacist contacts the physician providing care for the patient
to alert him/her and recommends alternative medications or doses.

 Assessments and followup care: Once the patient is stable, nurses screen for cognitive loss,
depression, and alcohol and drug use. They also perform risk assessments for falls, neglect,
or abuse; assess physical function and risk of followup problems; and refer patients to the
appropriate level of care. Within 24 hours of discharge, a geriatric social worker calls each
high-risk patient to check on his or her status and answer any questions. All patients receive a
followup phone call from an administrative assistant within a few days of discharge (typically
2-3 days and no more than 1 week) to help them address any challenges they may be facing,
such as obtaining medications, reducing household safety hazards, setting up home visits
from nurses, or arranging for hospice care.

DID IT WORK?
Results
Patients treated at the senior emergency center report high levels of satisfaction with their
treatment. The center has increased the number of patients identified as taking inappropriate
medication or medication doses, and has also experienced an increased volume of patients and low
rates of return visits to the ED.

 High patient satisfaction: A survey of 1,047 patients treated in the senior emergency center
between November 2008 and October 2009 found that 98 percent of respondents rated
their ED experience as excellent (selecting the top option). Additionally the following
percentage of respondents selected the top response to the listed question: 98
percent when asked if senior emergency center staff listened to them; 96.7 percent when
asked if staff kept them well informed; 97.3 percent when asked if staff were caring and
compassionate; 98.4 percent when asked about the noise level in and around their room;
87.2 percent when asked about the waiting time for tests or treatment; and 99 percent when
asked about the likelihood of recommending the senior center to others.

 Improved screening for inappropriate medications: The center averages 450 patient visits
each month, 50 percent of whom are prescribed 5 or more medications. Of these 450
patients, the "Senior Polypharmacy" referral has identified approximately 20
percent who were taking an inappropriate medication or medication dose that was
subsequently corrected.

 Increased patient volume: The volume of patients treated in the senior emergency center
increased 16 percent from 2008 to 2009, compared to a 10 percent increase in the hospital's
volume of nonsenior patients treated in the main ED.

 Few return visits: Since the center opened in November 2008, approximately 3 percent of
patients return to the ED within 72 hours, while 15 percent return within 30 days. Comparison
data specific to seniors are not available.

Evidence Rating
Suggestive: The evidence consists of post-implementation results from patient satisfaction surveys,
along with data on the percentage of patients who were taking an inappropriate medication or
medication dose, treated in the senior emergency center, and returned to the emergency
department after an initial visit.
HOW THEY DID IT
Context of the Innovation
Holy Cross Hospital, a 450-bed, not-for-profit teaching hospital located just north of Washington,
DC, primarily serves residents of Maryland's two largest jurisdictions, Montgomery and Prince
George's counties. The hospital offers inpatient and outpatient primary and specialty services,
with expertise in surgery, neuroscience, cancer, women and infants' care, and senior care. The rapid
growth in the population of senior citizens in the area, combined with the observation that the
typical emergency department is a challenging environment for many seniors, convinced hospital
leaders of the need to find ways to improve the experience of older patients in the ED.

Planning and Development Process

Key steps in the planning and development process included the following:

 Committee formation: In 2007, the hospital formed a steering committee comprising senior
hospital executives, the ED's medical director, two ED physicians, and five nurses to explore
how the hospital could enhance seniors' experience in the ED. The committee decided to
convert a large area adjoining the main ED into a separate emergency center for seniors.

 Consultation with outside experts and focus groups: Committee members met several times
with a geriatrician and professor of aging at University of Maryland Baltimore County's
Erickson School of Aging Studies. These specialists provided suggestions on how the new
area could be designed to reduce patient stress and anxiety. The committee also consulted
experts in lighting and audiology and held focus groups with community seniors who tested
out mattresses of varying thicknesses and offered insights on their priorities (such as wanting
warm blankets and to be kept informed).

 Key structural and policy decisions: Based on their consultations and research, the

committee settled on a design plan that called for eight rooms with the previously
described privacy, comfort, and safety features. After reviewing ED patient age patterns and
considering several possible minimum ages for eligibility, the committee decided that the
minimum age to qualify for treatment at the center should be 65.
  Fundraising: Each September, the hospital dedicates the proceeds from an annual
dinner/dance/auction to a specific project inside the hospital. Hospital executives agreed to
devote funds from the 2007 event to the construction of the senior emergency center.

 Center design and construction: In the fall of 2008, contractors converted the existing space
into the senior emergency center and installed the comfort and safety features.

 Training: Also in the fall, ED staff completed a 12-hour geriatric training program at the

hospital. These sessions, taught online, focused on topics such as treatment of specific
health issues, assessment and screening, and techniques for communicating with patients
whose hearing is impaired or who process information slowly due to neurological limitations.

 Opening: The senior emergency center opened in November 2008 with a ribbon-cutting

ceremony.

Resources Used and Skills Needed

 Staffing: The center is primarily staffed by physicians, nurses, and administrative personnel

who were already working in the regular ED; this staff now covers both EDs. A geriatric social
worker and geriatric nurse practitioner with significant expertise in geriatric care were hired
to work exclusively in the senior emergency center.

 Costs: Converting the existing space and purchasing the requisite equipment cost
approximately $150,000. Additional incremental operating costs include salaries and benefits
for the two newly hired individuals, along with other expenses associated with the space
(e.g., incremental utility costs).  

Funding Sources
Holy Cross Hospital pays for the program, including compensation of newly hired staff, from the
annual operational budget; as noted, funds to cover the conversion of the existing space and the
purchase of new equipment came from an annual fundraiser sponsored by the hospital.
ADOPTION CONSIDERATIONS
Getting Started with This Innovation

 Research patient demographics: Gain a solid understanding of the surrounding area's

population before deciding whether to set up a senior emergency center (or how large it
should be). As part of this process, consult with local municipalities to get estimates of how
rapidly the senior population is expected to grow in coming decades.

 Involve ED staff early: Include ED physicians and nurses from the outset, as their
involvement will likely make them champions for the new center.

 Seek hospital staff support outside the ED: Also engage other hospital staff members such as
allied health workers, physical plant personnel, and organizational planners, since the
opening of the center will impact their work.

 Solicit outside input: Experts from local universities and senior community volunteers often
contribute excellent ideas for enhancing comfort and safety.

Sustaining This Innovation

 Maintain focus on emergency care: Although it is feasible and beneficial to provide patients

at the senior emergency center with certain services they might not receive at a standard ED
(e.g., screening for additional health issues, assessing the risk of falls), expanding service
offerings too much creates the potential for the center to lose its focus on emergency care.
Providing in-depth examinations and treatment that patients could get elsewhere (e.g.,
in the main hospital or from primary care doctors or specialists) can lead to longer wait times
inside the ED. Keeping a close watch on patient volume can help ED administrators strike the
appropriate balance.

REACTION:
Having a separate area for the elderly is a great idea for not only does it promote satisfaction
and fast treatment to them, and also it can help in decreasing the mortality rate of the population.
Also, the focus of the team of the emergency department for older patients is maintained. This
would also enable them to improve health care management for the patients because what they
cater to is only a single age group.